Echocardiographic features of myocardial rupture after acute myocardial infarction on emergency echocardiography.

OBJECTIVE: Myocardial rupture is a fatal complication of acute myocardial infarction (AMI). Early diagnosis of myocardial rupture is feasible when emergency physicians (EPs) perform emergency transthoracic echocardiography (TTE). The purpose of this study was to report the echocardiographic features of myocardial rupture on emergency TTE performed by EPs in the emergency department (ED). METHODS: This was a retrospective and observational study involving consecutive adult patients presenting with AMI who underwent TTE performed by EPs in the ED of a single academic medical center from March 2008 to December 2019. RESULTS: Fifteen patients with myocardial rupture, including eight (53.3%) with free wall rupture (FWR), five (33.3%) with ventricular septal rupture (VSR), and two (13.3%) with FWR and VSR, were identified. Fourteen of the 15 patients (93.3%) were diagnosed on TTE performed by EPs. Diagnostic echocardiographic features were found in 100% of the patients with myocardial rupture, including pericardial effusion for FWR and a visible shunt on the interventricular septum for VSR. Additional echocardiographic features indicating myocardial rupture were thinning or aneurysmal dilatation in 10 patients (66.7%), undermined myocardium in six patients (40.0%), abnormal regional motions in six patients (40.0%), and pericardial hematoma in six patients (40.0%). CONCLUSION: Early diagnosis of myocardial rupture after AMI is possible using echocardiographic features on emergency TTE performed by EPs.

Seizure during hyperbaric oxygen therapy: experience at a single academic hospital in Korea.

Background: Hyperbaric oxygen (HBO2) therapy is a safe and well-tolerated treatment modality. Seizures, one of the most severe central nervous system side effects of HBO2 therapy, can occur. Episodes of seizures during HBO2 therapy have not yet been reported in countries such as Korea, where hyperbaric medicine is still in the developmental stage. Methods: The registry data of all patients treated with HBO2 therapy in a tertiary academic hospital in Korea were prospectively collected, and patients who developed seizures during HBO2 therapy between October 2016 and December 2019 were evaluated. In addition, we reviewed previous studies on occurrence of seizures during HBO2 therapy. Results: During the study period, a total of 10,425 treatments were provided to 1,308 patients. The most frequently treated indication was carbon monoxide (CO) poisoning ABSTRACT (n=547, 41.8%). During the HBO2 therapy sessions (total: 10,425), five seizure episodes occurred (patients with CO poisoning: n=4; patients with arterial gas embolism [AGE]: n=1). The frequency of seizures in patients with CO poisoning (0.148%) and AGE (3.448%) was significantly higher than that in patients with all indications (0.048%) (p=0.001). None of the patients had lasting effects due to the seizures. Conclusion: Our study revealed a similar frequency rate in terms of all indications and CO poisoning, and a slightly higher rate in AGE. Seizures were observed in patients with CO poisoning and AGE. Therefore, if clinicians plan to operate a hyperbaric center in a country like Korea, where there are several patients with acute CO poisoning, they should be prepared to handle seizures that may occur during HBO2 therapy.

Diagnosis of aortic dissection by transesophageal echocardiography during cardiopulmonary resuscitation.

OBJECTIVES: Early identification of the causes of cardiac arrest is helpful in determining the resuscitation measures during cardiopulmonary resuscitation (CPR). We aimed to evaluate the feasibility of transesophageal echocardiography (TEE) during CPR in diagnosing aortic dissection and the influence of aortic dissection on resuscitation outcome in adult patients with prolonged non-traumatic cardiac arrest. METHODS: Adult patients aged >20 years with non-traumatic cardiac arrest who underwent prolonged CPR (>10 min) and TEE examination during CPR were enrolled. The enrolled patients were grouped according to the presence of aortic dissection on TEE: the aortic dissection (AD) group and the non-AD group. Variables related to cardiac arrest event, CPR, and resuscitation outcome were compared between the two groups. RESULTS: Forty-five patients (median age, 71 years; 26 men) were enrolled. Ten (22.2%) and 35 (77.8%) patients were included in the AD and non-AD groups, respectively. No patients in the AD group survived. Aortic dissection on TEE was inversely related to the rate of return of spontaneous circulation on multivariate analysis (odds ratio, 0.019; 95% confidence interval, 0.001-0.750; p = .035). CONCLUSION: TEE is a useful tool for diagnosing aortic dissection as a cause of cardiac arrest during CPR. Aortic dissection is associated with poor resuscitation outcomes.

Intra-arrest transoesophageal echocardiographic findings and resuscitation outcomes.

BACKGROUND/AIM: The relationship between echocardiographic findings of intra-arrest TEE and resuscitation outcomes was not clearly identified. We assessed echocardiographic findings observed in intra-arrest TEE and its relationship with resuscitation outcomes. METHODS: This retrospective observational study analysed adult patients with non-traumatic out-of-hospital cardiac arrest who underwent TEE during cardiopulmonary resuscitation in the emergency department. Patients were grouped according to the presence of specific TEE findings with cardiac arrest. Resuscitation outcomes were compared between groups. RESULTS: The study enrolled 158 patients (108 males, median age: 72.5 years), 40 (25.3%) patients (TEE positive group) had specific TEE findings including possible causes of cardiac arrest in 31 (19.6%) and the sequela of cardiac arrest in 9 (5.7%) while 118 (74.7%) patients (TEE negative group) had no specific TEE findings. In the TEE positive group, TEE identified possible causes of cardiac arrest including aortic dissection in 19 (47.5%), pulmonary embolism in 8 (20.0%), cardiac tamponade in 4 (10.0%), and the sequela of cardiac arrest including intracardiac thrombi in 9 (22.5%) patients. No patients in the TEE positive group and 7 patients (5.9%) in the TEE negative group survived to hospital discharge. Return of spontaneous circulation rates were 27.5% and 39.8% in the TEE positive and TEE negative groups, respectively (p = 0.16). CONCLUSION: Intra-arrest TEE identifies specific findings related to causes of cardiac arrest. Presence of specific findings is associated with poor resuscitation outcomes.

Successful use of hyperbaric oxygen therapy for limb salvage of acute limb ischemia as a complication of acute carbon monoxide poisoning.

Acute limb ischemia (ALI) as a complication of acute carbon monoxide (CO) poisoning is rare. Several reports have utilized hyperbaric oxygen therapy (HBO2) as an adjunctive therapy for peripheral arterial diseases. However, no study has yet described the use of HBO2 for ALI precipitated by CO poisoning. Herein we report successful limb salvage achieved with adjunctive HBO2 and conventional therapies in a patient with CO-induced ALI. A 69-year-old man was admitted with acute CO poisoning; ALI of both lower extremities occurred on hospitalization day 3. Pre-existing risk factors for ALI other than CO were not definite. After conventional treatments including catheter-directed thrombolysis and endovascular thrombectomy, the right-side lesion remained and a left-side lesion was newly developed. In addition to prior therapies, 47 sessions of serial HBO2 were administered as adjunctive therapy, resulting in limb salvage. Acute CO poisoning can cause ALI as a rare complication. HBO2 may be utilized as an adjunctive treatment in ALI.

The effect of adjunctive hyperbaric oxygen therapy in patients with central retinal artery occlusion.

Purpose: Central retinal artery occlusion (CRAO) is an ophthalmic emergency with poor prognosis, despite diligent conventional treatment. According to the clinical recommendations of the Undersea and Hyperbaric Medical Society, hyperbaric oxygen (HBO2) is a potentially beneficial treatment; however, the benefit of adjunctive HBO2 in patients with CRAO in Korea remains unclear. The present study aimed to evaluate the effect of adjunctive HBO2 in patients with CRAO. Methods: This registry-based observational study included adult patients who presented to the emergency department or ophthalmology outpatient department within 24 hours of the onset of CRAO symptoms. Data of patients from October 2016 to February 2019 were analyzed. The patients were categorized into two groups according to the use of adjunctive HBO2: no HBO2 and HBO2. Result: During the study period, 34 consecutive patients were enrolled, of which 19 were included in the study. In the total cohort, 10 patients (52.6%) were treated with adjunctive HBO2. There were no statistically significant differences in terms of age, sex, comorbidities, duration from symptoms onset to hospital visit, presence of the cilioretinal artery, and use of anterior chamber paracentesis between the two groups. The HBO2 group showed significantly higher change in best-corrected visual acuity than the no HBO2 group (p=0.043). Conclusion: Patients with CRAO in the HBO2 group showed significantly greater visual improvement than those in the no-HBO2 group. Clinicians should consider adjunctive HBO2 in the treatment approach in patients with CRAO who visit the hospital within 24 hours of symptoms onset.

Operation of a hyperbaric oxygen therapy center in Korea: Report of our experience from a setting in its nascent stages.

Purpose: Hyperbaric medicine is nascent in Korea when compared to other developed countries, such as the United States and Japan. Our facility has been managed by physicians with certifications from the Undersea and Hyperbaric Medical Society (UHMS) and National Oceanic and Atmospheric Administration in diving and clinical diseases since October 2016. This study was conducted to share similar issues that are encountered during the establishment of a program in a new area through our experiences in the operation of a hyperbaric oxygen (HBO2) therapy center. Methods: In this retrospective observational study we collected data on HBO2 patients treated at our center between October 2016 and June 2018 after HBO2 was conducted by HBO2-certified physicians. We then compared demographic data of patients with data from January 2011 to September 2015 - before HBO2 operations were conducted by HBO2-certified physicians. Result: A total of 692 patients received 5,130 treatments. Twelve indicated diseases were treated using HBO2 therapy. Fifty-six critically ill patients with intubation received HBO2. Although two patients experienced seizure due to oxygen toxicity during the study period, certified physicians and inside attendant took immediate corrective action. Conclusion: After the establishment of the HBO2 center operated by physicians with certification, more patients, including critically ill patients, received HBO2 safely for various diseases. In order to improve the practice of hyperbaric medicine in Korea, the Korean Academy of Undersea and Hyperbaric Medicine (KAUHM), an advanced and well-organized academic society, should communicate often with HBO2 centers, with the aim to set Korean education programs at UHMS course levels and increase reimbursement for HBO2 therapy.

The usefulness of non-contrast abdominal computed tomography for detection of residual drugs in the stomach of patients with acute drug overdose.

Objectives: If clinicians can know that there are many life-threatening drugs left in the stomach through a non-invasive method over 60 min after drugs ingestion, it may be preferable to minimize absorption of remnant drugs through various methods according to the characteristic of the drug. Computed tomography (CT) has gained wide acceptance in the detection of drug mules. Therefore, we evaluated the prevalence of drugs in the gastric lumen using abdominal non-contrast CT, performed over 60 min after acute drug poisoning. Materials and methods: This was a prospective cohort study of patients with acute drug poisoning who were admitted to the emergency department (ED) between March 2017 and February 2018. If the patient visited the ED over 60 min after ingestion of life-threatening or unknown drugs, non-contrast CT scan was performed. "Presence of drugs" was defined in the non-contrast CT as a round-shaped lesion with higher density than the gastric mucosa. In addition, "positive radiodense image" was defined as that with higher density than the gastric mucosa regardless of drug appearance in the non-contrast CT scan. Results: Among a total of 482 patients with drug poisoning, 140 were finally included in the study. Residual drugs were detected in 36 patients (25.7%). Further, regardless of the presence of drugs, 58 patients (41.4%) showed positive radiodense image in the stomach. The median Hounsfield unit of drugs was 131.5 and that of food materials in the stomach was 34.5. Total duration of hospital stay was significantly longer in the "absence of drug" group and sustained-release drugs were detected more frequently in the "presence of drugs" group. Conclusions: Detection rate of drugs and presence of positive radiodense image, regardless of drug appearance, were as high as 25.7% and 41.4%, respectively. Sustained-release drugs were detected more frequently in the "presence of drugs" group.

Single Ventilation during Cardiopulmonary Resuscitation Results in Better Neurological Outcomes in a Porcine Model of Cardiac Arrest.

PURPOSE: Recent basic life support (BLS) guidelines recommend a 30:2 compression-to-ventilation ratio (CV2) or chest compression-only cardiopulmonary resuscitation (CC); however, there are inevitable risks of interruption of high-quality cardiopulmonary resuscitation (CPR) in CV2 and hypoxemia in CC. In this study, we compared the short-term outcomes among CC, CV2, and 30:1 CV ratio (CV1). MATERIALS AND METHODS: In total, 42 pigs were randomly assigned to CC, CV1, or CV2 groups. After induction of ventricular fibrillation (VF), we observed pigs for 2 minutes without any intervention. Thereafter, BLS was started according to the assigned method and performed for 8 minutes. Defibrillation was performed after BLS and repeated every 2 minutes, followed by rhythm analysis. Advanced cardiac life support, including continuous chest compression with ventilation every 6 seconds and intravenous injection of 1 mg epinephrine every 4 minutes, was performed until the return of spontaneous circulation (ROSC) or 22 minutes after VF induction. Hemodynamic parameters and arterial blood gas profiles were compared among groups. ROSC, 24-hour survival, and neurologic outcomes were evaluated at 24 hours. RESULTS: The hemodynamic parameters during CPR did not differ among the study groups. Partial pressure of oxygen in arterial blood and arterial oxygen saturation were lowest in the CC group, compared to those in the other groups, during the BLS period (p=0.002 and p<0.001, respectively). The CV1 groups showed a significantly higher rate of favorable neurologic outcome (swine CPC 1 or 2) than the other groups (p=0.044). CONCLUSION: CPR with CV1 could promote better neurologic outcome than CV2 and CC.